Staff Immunization History Form

Name of Staff:______Staff Birthdate:______

MEASLES, MUMPS, AND RUBELLA (MMR)
One dose of MMR vaccine is recommended for all staff. Staff at high risk (nurses, international travelers, or college students) are recommended to get two doses. This vaccine is not required for those born before January 1, 1957.
Dose 1 date: ______
Dose 2 date: ______
Documentation of Immunity
I certify that the person named above has laboratory evidence of immunity to measles, mumps, or rubella virus and does not need MMR vaccine.
Titer (laboratory evidence of immunity) Result/Date:______
VARICELLA (CHICKENPOX)
Two doses of varicella vaccine are recommended unless staff had verification of chickenpox disease or herpes zoster from a healthcare provider.
Dose 1 date: ______
Dose 2 date: ______
Dateof Chickenpox disease:______
Documentation of Immunity
I certify that the person named above has laboratory evidence of immunity to varicella virus and does not need varicella vaccine.
Titer (laboratory evidence of immunity) Result/Date:______
HEPATITIS B*
Three doses of hepatitis B vaccine are recommended or laboratory evidence of immunity.
Dose 1 date: ______
Dose 2 date: ______
Dose 3 date: ______
Documentation of Immunity
I certify that the person named above has laboratory evidence of immunity to hepatitis B virus and does not need Hepatitis B vaccine.
Titer(laboratory evidence of immunity) Result/Date: ______
TETANUS, DIPHTHERIA, PERTUSSIS (Tdap)/TETANUS-DIPHTHERIA (Td)
One Tdap recommended, then Td booster every 10 years.
Tdap date: ______
Td date (most recent): ______
INFLUENZA (FLU)
Flu vaccine recommended every year.
Date (most recent): ______

School or Child Care:______School District:______

EMPLOYEE IMMUNIZATION EXEMPTION FORM
Exemption
I have read information concerning the vaccines and understand that I may be at risk of getting a vaccine-preventable illness from an unvaccinated child or student, or staff member. However, I am choosing to decline vaccination at this time. By declining vaccination, I understand that I am at risk of getting a vaccine-preventable illness.
I understand that in the event of a vaccine-preventable disease outbreak, I may not be allowed to work during the outbreak. Some outbreaks may last more than two weeks. I decline the following vaccines at this time (check all that apply):
Vaccine / Medical / Personal
Hepatitis B
MMR
Tdap/Td
Varicella
Influenza
Staff Signature Date(mm/dd/yyyy)
CERTIFICATION
I certify that the immunization information provided is correct. I give permission to the school districtor early learning center to share immunization information with the Immunization Information System and coordinate healthcare.
Staff Signature Date(mm/dd/yyyy)
Health Care Provider Signature or Stamp Date (mm/dd/yyyy)

*For more information about Labor and Industries rules about the hepatitis B vaccine and potential occupational exposure to bloodborne pathogens, please go here:

If you have a disability and need this document in another format, please call 1-800-525-0127 (TDD/TTY 711).

DOH 348-496July 2017

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